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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Many doctors from overseas are left feeling lost, anxious and not ready to care for patients after joining the NHS because they are not properly looked after, research has found. Many international medical graduates (IMGs) feel the NHS does not help them prepare for life as a doctor in the UK and the practicalities of moving to a new country, according to a survey. Almost six in 10 (58%) of those questioned thought their induction was inadequate, and almost half (48%) felt anxious about starting to perform clinical duties in the UK. The Medical Protection Society (MPS), which surveyed 737 IMGs working in England, said the results showed that too many foreign-trained doctors were “still being let down” professionally and personally by the NHS. One doctor said: “I was very anxious and worried as working clinically without induction and [a] very brief period of shadowing … I was just lost.” Another said: “I asked several times about induction, to be told that I will just learn on the job and ‘it will be fine’.” Read full story Source: The Guardian, 28 June 2024
  2. News Article
    The NHS Race and Health Observatory has raised fundamental concerns about racism towards maternity patients after several cases have come to light in recent months, including midwives branding patients as “Asian princesses”. The watchdog’s intervention follows regulators identifying patterns of racist and discriminatory behaviour at the maternity departments of two large hospital trusts and a smaller general hospital in the last six months. The observatory’s CEO Habib Naqvi told HSJ he was “deeply concerned” by the seriousness of the issues raised. He added that “discriminatory behaviours and ways of working… [can] lead to hostile and unsupportive learning environments… impact patient care and safety, and also seriously undermine the NHS’s goal of attracting and retaining its workforce”. Examples given included the term “Asian princess” being used by midwives in reference to brown-skinned women requesting pain relief during labour. The students also described a “disregard” from some midwives towards black and brown-skinned women, particularly where English was not their first language. It was also reported when Asian women verbalised their pain during labour, some midwives responded with “Oh, they are all like this”, while additional derogatory comments were made towards asylum seekers, that “they are playing the system”, the NHSE team’s report said. Read full story (paywalled) Source: HSJ, 28 June 2024
  3. News Article
    An NHS England document has confirmed that that it wants to ‘optimise’ GP referrals to secondary care via an enhanced model of advice and guidance. GP leaders recently raised concerns that NHS England had encouraged Integrated Care Boards (ICBs) to adopt the ‘advice and refer’ model, effectively replacing traditional GP referrals and adding barriers for patients in accessing secondary care. At the time, NHS England did not address concerns about this specific model, but Pulse has now seen a ‘framework’ document which encouraged local commissioners to ‘strengthen’ specialist advice services in order to ‘optimise’ referrals. The guidance suggested the use of the ‘advice and refer’ model, which means all referrals or advice requests from GPs ‘come in through one route’ and directly bookable appointments are ‘discouraged or removed’. Under this service, all referrals are then ‘triaged’, allowing hospitals to reject referrals and send them back to GPs with advice. This mechanism removes the option for GPs to send standard referrals, whereas the usual model of advice and guidance (A&G) allows GPs to seek advice if they wish, but maintains the direct referral route. NHS England emphasised its commitment to empowering regions to ‘develop diverse models’ of specialist advice in line with their local needs. Read full story Source: Pulse, 26 June 2024
  4. Content Article
    The new PIER approach will enable the effective management of acute physical deterioration in health and care and will apply to all conditions, clinical settings and specialities. The new PIER approach views deterioration as a whole pathway which is supported by systems rather than only advocating a single strategy for identification. Acute physical deterioration is the rapid worsening of a patient’s condition. It can be identified from changes in physiology, such as respiratory rate, blood pressure or consciousness, or more subtle signs, such as not eating and a patient or their family’s concerns and observations around wellness, mental status or behaviour. Deterioration can occur in any health and care setting and is the common pathway in all emergency admissions, prolonged illnesses and deaths.
  5. News Article
    Kansas is the latest US state to file a lawsuit against Pfizer, accusing the pharmaceutical giant of misleading the public about the safety and effectiveness of its Covid-19 vaccine. Kansas Attorney General Kris Kobach claims that Pfizer knew about the risks associated with its vaccine, “including myocarditis and pericarditis, failed pregnancies, and deaths” but failed to disclose this information to the public. The 179-page lawsuit also alleges that Pfizer made ‘false and misleading’ statements regarding the vaccine's ability to prevent viral transmission, its waning effectiveness and its ability to protect against new variants of the virus. “To keep the public from learning the truth, Pfizer worked to censor speech on social media that questioned Pfizer’s claims about its Covid-19 vaccine,” alleges the lawsuit. Read full story Source: Maryanne Demasi, 23 June 2024
  6. Content Article
    On the 22 January 2024 Assistant Coroner Sarah Bourke began an investigation into the death of Anoush Summers who died aged 77, on the 14 January 2024 at Homerton University Hospital.   The deceased was a frail lady who was prone to falls. She lived at home, alone, with carers who visited her twice a day. She had a wrist alarm. The wrist alarm was reported as broken and not working on the 6 January 2024, but it was not repaired or replaced. Sometime after 4.45pm on 11 January 2024 the deceased fell at home. She was found the next day by a carer, wearing her wrist alarm and taken to hospital where she died on 14 January 2024 of hypothermia. The absence of a working wrist alarm prevented her from being found sooner that she was and probably contributed to her death.
  7. News Article
    NHS England has warned trusts corridor care “must not be considered the norm”, adding that the failings exposed by a recent undercover documentary were “not acceptable”. In a letter to boards after a Dispatches documentary filmed at Royal Shrewsbury Hospital aired on Monday, NHSE’s chief operating officer, chief nursing officer, national medical director and director of urgent and emergency care warned trusts they must ensure basic standards of care. The note, seen by HSJ, described footage filmed at RSH’s emergency department as “stark”, adding that it highlighted the service some patients receive is “not acceptable”. The documentary captured many instances of patients being treated in corridors, and the letter said corridor care or that delivered outside a normal cubicle environment “must not be considered the norm”. NHSE added: “It should only be in periods of escalation and with board-level oversight at trust and system level… where it is deemed a necessity… it must be provided in the safest and most effective manner possible, for the shortest period of time… with patient dignity and respect being maintained throughout.” Read full story (paywalled) Source: HSJ, 27 June 2024 Related reading on the hub: A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift
  8. News Article
    An assistant coroner has warned an east London council more people may die if it does not take action, after a "frail lady who was prone to falls" died of hypothermia at her home. Anoush Summers, 77, died in hospital in January after a fall days earlier. In a prevention of future deaths report, external, assistant coroner Edwin Buckett said Ms Summers' inquest concluded "the absence of a working wrist alarm prevented her from being found sooner than she was and probably contributed to her death". Ms Summers lived alone but received help from two carers from Supreme Care Services, and she was visited twice a day. After falling at home on 11 January, she was found the next day at 09:00 GMT wearing her wrist alarm and was taken to hospital. She died of hypothermia at Homerton University Hospital on 14 January. The assistant coroner said among issues he identified in her case "giving rise to concern" were: Her wrist alarm had been reported as broken and not working on 6 January, but "this was not replaced or repaired by the company engaged by the local authority", which meant Ms Summers could not call for help as "it did not work" None of the carers who attended her home after the wrist alarm broke on 6 January "ensured that steps were taken to replace the alarm" or reported the matter to the local authority The last carer to see her, who visited on 11 January, "was not aware that the wrist alarm did not work as she had not read the care notes", and "no clear instruction was given" about the extent to which carers should read these notes "None of the carers had been given any training, instruction or guidance on the testing of wrist alarms to ensure they worked properly when attending" There was not a "clear system identified between the company providing carers and the local authority as to the duties and responsibilities of each in the reporting of faults with wrist alarms" Read full story Source: BBC News, 26 June 2024
  9. Content Article
    This paper reviews the key perspectives on human error and analyses the core theories and methods developed and applied over the last 60 years. These theories and methods have sought to improve our understanding of what human error is, and how and why it occurs, to facilitate the prediction of errors and use these insights to support safer work and societal systems. Yet, while this area of Ergonomics and Human Factors (EHF) has been influential and long-standing, the benefits of the ‘human error approach’ to understanding accidents and optimising system performance have been questioned. This state of science review analyses the construct of human error within EHF. It then discusses the key conceptual difficulties the construct faces in an era of systems EHF. Finally, a way forward is proposed to prompt further discussion within the EHF community.
  10. Content Article
    Clinical safety is about keeping patients safe. It applies not only to us in the NHS, or social care organisations, but to you when building healthcare software. The law requires you to ensure your software is clinically safe, which means minimising the potential for harm to patients. This page on the NHS Digital website explains what you need to know about clinical safety when building healthcare software.
  11. Content Article
    In a new video masterclass, Lisa Annaly, Head of Analytic Content at the Care Quality Commission, talks through how scoring features in their new assessment model. Lisa also answers some frequently asked questions to help your understanding of our scoring methodology.
  12. Content Article
    The latest report in Public Policy Project’s Medicines and Pharmacy programme calls for transformation across the pharmacy sector to unlock medicines optimisation which creates true system value. The report highlights that medicines optimisation has significant potential to contribute to delivering integrated care priorities, such as improving population health and reducing inequalities. As ICSs grapple with financial challenges, medicines, as the second highest cost to the NHS, represent a critical opportunity to improve patient outcomes and deliver better value for money. 
  13. News Article
    A cancer patient has told Sky News it's "terrifying" for her health that junior doctors are striking again from Thursday. The NHS is expecting "major disruption" during the five-day strike as medics in England walk out over pay amid a yellow health alert heatwave and ongoing disruption to some services because of a ransomware cyber attack earlier this month. Major hospitals Guys' and St Thomas' and King's in London are still running at reduced capacity after the incident. Cancer survivor Donia Youssef has annual colonoscopies but her last was cancelled because of previous industrial action by junior doctors. Donia, from Grays in Essex, said: "It's a worry as a mum with two young children and I was on the list. It got cancelled. First time because of the strikes. And after that I didn't hear from them. So I kept pushing. Nothing. It was just more delays. I was just kept waiting. "[They said]: 'There's a backlog. We'll get back to you. There's a backlog, they're getting through. We'll let you know if there's any cancellations.'" "It's like months later. Nothing. So eventually, because the symptoms are getting worse, I decided to pay." Donia was so scared of her health worsening she paid for private treatment, a cost she could barely afford. And now, as a cancer survivor, every time there's a fresh round of strikes she is filled with dread. "I get scared. I can't get [treatment] on the private and a lot of it's really expensive. So, yeah, it's terrifying. So you're constantly aware," she said. Read full story Source: Sky News, 27 June 2024
  14. News Article
    The Care Quality Commission has admitted it is failing to keep patients “safe” and is losing the confidence of ministers and the NHS, HSJ has discovered. HSJ has seen part of an internal “problem statement” produced by interim chief executive Kate Terroni. It says that “stakeholders and the Department of Health and Social Care are losing confidence in our ability to deliver our purpose”. The statement adds: “The way we work is not working and we are not consistently keeping people who use services safe. “Our people are not able to effectively identify and manage risk and encourage improvement and innovation. “Our organisational structure, flow of decision making, roles, internal and external relationships do not promote a productive and credible way of working.” Read full story (paywalled) Source: HSJ, 26 June 2024
  15. Event
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    Join Patients for Patient Safety US for 3 days of events centred around World Patient Safety Day (WPSD) 2024. PFPS US urges Americans impacted by missed or delayed diagnoses, bias or medical error to convene in Washington, DC for a Summit held September 15-17, 2024. The World Health Organization designates 17 September 17 as World Patient Safety Day, and WPSD 2024’s theme is Improving Diagnosis for Patient Safety. Find the full Summit event list at https://www.pfps.us/wpsd-2024, including: Sunday 15 September: Welcome reception and dinner at Johns Hopkins University Bloomberg Center to launch Project PIVOT, a national project identifying patient-prioritized outcomes and experiences and collaboration with patient organizations, US Department of Health and Human Services, Johns Hopkins University, Harvard Medical School and others. Monday 16 September: Participants visit Capitol Hill to urge Congressional leaders to ACT Now for patient safety, diagnostic safety and health equity solutions. ACT Now is PFPS US’s urgent request to leaders for Accountability, Coordination, and Transparency in health care. Later, PFPS US and AcademyHealth co-host a film premiere of The Pitch: The Next Generation of Patient Safety. From immersive tech to AI machine learning, innovations are finally making waves in medicine with the goal of safer health care. The Pitch gives a unique look at the American health care system’s ongoing challenge to embrace the next generation of patient safety. Tuesday 17 September, World Patient Safety Day: The March for Patient Safety begins at Freedom Plaza and ends with a ceremony on the US Capitol Lawn, where marchers will remember those whose lives have been lost to or impacted by preventable harm. Afterwards, PFPS US and the Bloomberg Center co-host a World Patient Safety Day Leadership Briefing with government leaders. Further information and to sign up
  16. Content Article
    Few previous studies evaluating the benefits of diagnostic decision support systems have simultaneously measured changes in diagnostic quality and clinical management prompted by use of the system. This report describes a reliable and valid scoring technique to measure the quality of clinical decision plans in an acute medical setting, where diagnostic decision support tools might prove most useful.
  17. Content Article
    To give patients and their carers the flexibility to arrange their follow-up appointments as and when they need them, NHS England is supporting providers to roll out patient initiated follow-up (PIFU). PIFU is when a patient initiates an appointment when they need one, based on their symptoms and individual circumstances. It can be used with patients with long or short-term conditions in a broad range of specialties including dermatology, rheumatology and cancer. PIFU is not a new concept, and commonly goes by a number of other names including open access follow-up, patient led follow-up, patient triggered follow-up, patient initiated appointments, supported self-managed follow-up, self-managed follow-up, see on symptom, open appointments, open self-referral appointments or patient-activated care. The approach helps empower patients to manage their own condition and plays a key role in enabling shared decision making and supported self-management in line with the personalised care agenda.
  18. News Article
    A patient in a West Midlands A&E was forced to urinate while lying in a corridor as another was left crying in agony for hours in an undercover report highlighting the NHS’ emergency care crisis. A Channel 4 Dispatches programme has exposed the “suffering and indignity faced by patients on a daily basis” after an undercover reporter secretly filmed himself working as a trainee healthcare assistant inside the emergency department of the Royal Shrewsbury Hospital for two months. The footage, which aired on Monday night, shows one patient waiting 30 hours in a “fit to sit” area while a suspected stroke sufferer was there for 24 hours, the broadcaster said. In one clip, an elderly man was forced to urinate in a trolley on the corridor in full view of staff and other patients, while in another a woman is left crying in agony for hours. Nurses are also seen discussing how one of their patients was forced to wait a staggering 46 hours for care and at one point the footage shows large pools of blood on the floor. Experts have said while the scenes were “shocking” and “harrowing” they were not unique to the Royal Shrewsbury Hospital and are occurring in hospitals across England. Read full story Source: The Independent, 25 June 2024
  19. News Article
    Almost half of long-term antidepressant users could stop taking the medication with GP support and access to internet or telephone helplines, a study suggests. Scientists said more than 40% of people involved in the research who were well and not at risk of relapse managed to come off the drugs with advice from their doctors. They also discovered that patients who could access online support and psychologists by phone had lower rates of depression, fewer withdrawal symptoms and reported better mental wellbeing. Prof Tony Kendrick, of Southampton University, who was the lead author of the research, said the findings were significant because they showed high numbers of patients withdrawing from the drugs without the need for costly intense therapy sessions. He said: “This approach could eliminate the risk of serious side-effects for patients using antidepressants for long periods who have concerns about withdrawal. “Offering patients internet and psychologist telephone support is also cost-effective for the NHS. Our findings show that support not only improves patient outcomes but also tends to reduce the burden on primary healthcare while people taper off antidepressants.” Read full story Source: The Guardian, 26 June 2024
  20. News Article
    The NHS is having to provide emergency care to rising numbers of patients suffering serious complications following weight loss surgery and hair transplants abroad amid a “boom” in medical tourism, doctors have warned. Medics said they were being left to “pick up the pieces” as more Britons seeking cheap operations overseas return with infections and other issues. In some cases, patients are dying as a result of botched surgeries performed in other countries. Hospitals have even had to cancel elective procedures for patients because beds were being taken up by someone who needed an overseas procedure fixed. There were also concerns over patients buying weight loss drugs, including Wegovy, abroad without receiving the necessary “wraparound” care, doctors said. The British Medical Association’s annual meeting in Belfast heard there had been a “boom” in surgical tourism, which was “leading to a rise in serious post-surgery complications and deaths”. Read full story Source: The Guardian, 25 June 2024
  21. News Article
    The UK is at a "tipping point", with low uptake of routine vaccinations putting children at risk of catching severe diseases, health officials say. Stalling vaccination rates against some diseases, such as whooping cough and measles, means population immunity is no longer high enough to stop outbreaks. Latest figures from the UK Health Security Agency (UKHSA), for January-March, show a small increase in some vaccinations, including a 0.3% rise in pre-school booster jabs given to under-fives. But targets are still being missed. The World Health Organization (WHO) target is for 95% of under-fives to be vaccinated. And for the six-in-one jab - against whooping cough, polio and tetanus - and measles, mumps and rubella (MMR) vaccine this was exceeded in Scotland and Wales. But for the UK as a whole only 91.5% of under-twos had received the six-in-one jab - and among the whole under-five age group, the proportion was just 84.5%. he UK's vaccine committee head, paediatrician Prof Sir Andrew Pollard, is "really worried" by the recent rise in whooping, or "100-day", cough, also known as pertussis, which can be particularly serious for babies and infants. "We've already seen some deaths from the most recent outbreak," He told BBC News. "We're really at a tipping point, where there's a real risk for more children getting seriously ill or [dying] from diseases we can prevent." Read full story Source: BBC News, 25 June 2024
  22. Content Article
    Caring Corner is a podcast hosted by Katy Fisher and Kayleigh Barnett sharing real stories of Appreciative inquiry in health and care.
  23. Event
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    NIHR Central London Patient Safety Research Collaboration (CL PSRC) is proud to present the Learning Academy Monthly Safety Lectures. First in the series is Professor Sir Bruce Keogh, previous NHS National Medical Director, and currently the Chair of Birmingham Women's and Children's NHS Foundation Trust. A cardiac surgeon who previously worked at the Middlesex Hospital and Heart Hospital at Westmoreland Street, Professor Sir Bruce will be talking about his time clinically leading the NHS, his reflections on The Keogh Review into patient safety at NHS Hospitals (2013) and the impact that this review and other inquiries have had on NHS Patient Safety. Register
  24. Event
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    If you did a quality improvement project related to patient care, have you considered publishing the results? Sharing your project can help others learn from and replicate it, and benefit patients far and wide. It isn’t as hard as you might think! The Patient Safety online Master Class Writing Workshop in Quality Improvement Studies teaches the skills you need to turn your QI project into a manuscript. Session 1: Introduction to Writing a QI Study. Learn the typical elements of a published QI study so you can write one yourself. Thursday, August 29, 4–6 p.m. ET Session 2: Roundtable Manuscript Critique and Discussion. Review your manuscript with other participants tohelp revise it for publication. Thursday, October 10, 4–6 p.m. Further information
  25. Content Article
    In the wake of reports linking IT flaws to deaths of patients and the recent cyber attack on pathology services in south east London, Chris Fleming in an article for Digital Health calls for radical change to make digital safer and more effective
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